Social Turmoil, Psychopharmacology, and Treatment of Alcohol Use Disorder

Historians believe that alcohol was the first psychoactive drug manufactured for consumption by humankind. This occurred somewhere around 10,000 years ago (Capuzzi & Stauffer, 2016). Today alcohol is the most used intoxicant in the United States. Around 70% of adults report consuming alcohol within the past year. Of these, about one fourth report binge drinking within the past month (Gateway Foundation, 2020). The negative consequences of alcohol consumption both for the drinkers themselves as well as for society at large are often devastating. Millions of Americans find themselves trapped by an alcohol use disorder (AUD) and many more are on the way to developing an AUD. This essay looks at the historical context and current societal concerns regarding AUD, the psychopharmacology and current trends in treatment of AUD, and the significance to the counseling profession and future implications.

The American Historical Context

Alcohol was typically used by the American colonists for its curative properties as an anesthetic and a sedative rather than for intoxication. Although, it was not long before alcohol grew to be used as a vice in America. By 1784, the consumption of alcohol for intoxication had become sufficiently prevalent that Dr. Benjamin Rush began to write about the disease of alcoholism and its effects on society. Temperance movements developed in the early 1800’s, many of which drew on Dr. Rush’s teachings. Initially the goal of these movements was to promote drinking in moderation. However, by the mid-1800’s, many of the temperance movements shifted toward promoting total abstinence. One such group was the Washingtonian Total Abstinence Society founded in 1840. The Washingtonians recruited members in local taverns. They met in closed, alcoholics only meetings to share personal experiences and

encourage sobriety. Eventually, this became a model for future 12-step groups. Another group, the Women’s Christian Temperance Movement worked vigorously to shut down saloons (Capuzzi & Stauffer, 2016).

The antipathy against alcohol consumption continued to grow in America until Prohibition was finally enacted in 1920 through the Volstead Act. While the Prohibition moderately curtailed the consumption of alcohol in the United States, its bigger impact was to push alcohol sales and consumption underground leading to the development of organized crime and government corruption. Once American society realized that the negative consequences of Prohibition were worse than the negative consequences of legalizing alcohol, the Prohibition was easily repealed in 1933 (Capuzzi & Stauffer, 2016).

After the repeal of Prohibition, state governments quickly acted to limit alcohol-related problems through taxation as well as by placing restrictions on the sale of alcohol. State governments now regulate the number, size, location and hours of business for establishments that serve alcohol. The age of 21 has been adopted as the minimum legal drinking age in most states. Limitations have been put on the advertising of alcoholic products. Finally, most states have instituted criminal penalties for driving with a blood alcohol content of 0.08 or higher (Capuzzi & Stauffer, 2016).

Societal Concerns Regarding AUD

In the United States today we see that there are multiple tragic concomitant consequences that have come with the legalization of alcohol. One such problem is binge drinking, that is consuming five or more drinks in two hours for men or four or more drinks for women.

Approximately 28% of young adults, age eighteen to thirty-five, engage in binge drinking. Binge

drinking not only increases the likelihood of developing alcohol use disorder, but it greatly increases the risks of other concomitant consequences from consuming alcohol such as those that follow (Levinthal, 2016).

Probably the most common concomitant consequence of alcohol consumption is injury and death. Approximately 50% of trauma center cases in the United States are related to alcohol consumption. Alcohol related accidents and injuries are the third leading cause of death in the United States after cardiovascular disease and cancer (Capuzzi & Stauffer, 2016). Typically, we think of car accidents as the source of alcohol related accidents and deaths. We may feel that this is adequately addressed through the laws that are in place that prohibit driving under the influence of alcohol. However, alcohol related deaths can occur from a variety of other situations such as using machinery, accidental drowning, suicide, violent behavior, drug interactions and asphyxiation (Capuzzi & Stauffer, 2016).

Harmful drug interactions can occur when consuming alcohol along with illicit drugs, prescription medications, or even over-the-counter medications. Alcohol’s interaction effect is variable depending on the drug that it is mixed with. In some cases, alcohol will mitigate or even nullify the effect of the other drug, in other cases it will greatly enhance it, in other cases it will make the drug harmful or toxic. Some side effects from mixing alcohol and other drugs include nausea, vomiting, headaches, drowsiness, fainting, loss of coordination, internal bleeding, heart problems, difficulties breathing, and death. These issues are especially relevant for older people as their bodies metabolize alcohol more slowly and older people tend to take more medications, which increases the likelihood of an interaction with the alcohol (NIAAA, 2020).

Mixing alcohol with illicit drugs, which is often done to increase the euphoric effect, can be lethal. Mixing alcohol and cocaine has an even greater excitatory effect on blood pressure and heart rate than cocaine alone and increases the likelihood of death by a factor of twenty. Mixing alcohol with barbiturates similarly results in a synergistic effect that is much greater than that of the barbiturates alone and can result in death. Some alcoholics use benzodiazepines to reduce anxiety and withdrawal symptoms, which can likewise be a lethal combination. Finally, it is not uncommon for methadone-maintenance users to use alcohol as a substitution for opioids, which can have fatal consequences (Levinthal, 2016).

Finally, alcohol often plays a role in date-rape. Date-rape drugs, like GHB, are often slipped into an unsuspecting victim’s drink. The alcohol serves to enhance the effect of the drug leading to unconsciousness and subsequent amnesia. Further, alcohol, itself, is actually the most frequent used drug in date-rape. Once a potential victim becomes intoxicated through their own alcohol consumption, they can be easily preyed upon (Levinthal, 2016).

Psychopharmacology of Alcohol

Alcohol absorption starts in the stomach where about 20% of the alcohol is absorbed into the bloodstream. The remaining 80% is absorbed in the upper portion of the small intestine.

Alcohol is soluble in both fat and water making its absorption into the bloodstream quite rapid (Levinthal, 2016). Alcohol is also metabolized quickly with most of the alcohol leaving the bloodstream within 12 hours of consumption (Capuzzi & Stauffer, 2016). The fact that alcohol is fat soluble means that about 90% of the alcohol passes the blood-brain barrier. Alcohol affects multiple neurotransmitters, though its principal effect is the stimulation of GABA receptors. The result is inhibition of the functioning of the brain. Initially, the cerebral cortex is inhibited

resulting in impaired judgement and thinking. When larger amounts of alcohol are consumed, lower brain regions are inhibited as well. Sensorimotor skills become impaired making it dangerous to drive a car or operate machinery. There is an increased potential to engage in aggressive or violent acts as well (Levinthal, 2016). Gaps in memory, known as blackouts, may occur as the transfer of memories from short-term to long-term memory is blocked. Eventually, the drinker may lose consciousness or simply fall asleep (NIAAA, Interrupted Memories, 2021). Too much alcohol will inhibit the respiratory system in the medulla in which case death through asphyxiation may occur (Levinthal, 2016).

Sustained alcohol consumption over a period of time will eventually result in developing tolerance. That is, the user will need to consume more alcohol to achieve the same effect that they initially experienced. Consequently, someone who believes that they “hold their alcohol well” most likely has developed tolerance and their drinking is probably more problematic than they realize (Levinthal, 2016). Withdrawal symptoms may start to occur between six to forty- eight hours after the last drink was consumed. Symptoms include insomnia, disrupted sleep, gastrointestinal irritation, nausea, vertigo, fatigue, weakness, headache, muscle aches, sensitivity to light and sound, anxiety, irritability, and high blood pressure (NIAAA, Hangovers, 2021). In severe cases, delirium tremens (DTs) can occur which symptoms include disorientation, confusion, sweating, fever, nightmares, hallucinations, heart failure, and dehydration. DTs can result in death if not treated (Levinthal, 2016).

Detoxification and Treatment

Acute Detoxification

Flushing the alcohol from the body through a period of abstinence is the first stage of treating someone with AUD. The withdrawal symptoms described above typically last one to two weeks. Withdrawal symptoms can change quickly and become severe. Therefore, detoxification under the care of medical professionals in a hospital or rehabilitation facility is the safest approach to take. During the initial 6-12 hours of detoxification symptoms such as headaches, anxiety, shaking, nausea, and irritability are likely to be experienced. These tend to grow in severity and pain over the next two days during which disorientation, hand tremors, seizures, hallucinations, and panic attacks may be experienced. During days 3-7 of the detoxification are when DTs are most likely to occur. Other withdrawal symptoms may come and go during this time as well. During the second week of detoxification many of the withdrawal symptoms will taper off and stop. However, minor withdrawal symptoms may continue for a few months to a year. These include anxiety, low energy, trouble sleeping and delayed reflexes. This prolonged withdrawal is referred to as post-acute withdrawal syndrome (PAWS) (Galbicsek, 2021).

Medications Used to Treat AUD

Several medications are useful in the detoxification and ongoing treatment of a AUD. Benzodiazepines such as Librium, Lorazepam, and Diazepam are frequently used to reduce withdrawal symptom such as agitation, insomnia, anxiety, muscle spasms and seizures (Juergens, 2021). While effective in treating withdrawal symptoms, benzodiazepines cause sedation, memory deficits, respiratory depression and are addictive (Capuzzi & Stauffer, 2016).

Therefore, incorporating other medications can be beneficial. Anti-convulsants such as Levetiracetam, Baclofen, and Oxcarbazepine are often used during detoxification. These

medications not only inhibit seizures but have been found to reduce cravings as well (Capuzzi & Stauffer, 2016).

Several medications exist to help with ongoing treatment of an AUD. Disulfiram is a medication that negatively interacts with alcohol to cause flushing of the face, rapid heart rate, palpitations, nausea, and vomiting. It can be used as a form of aversion therapy. Unfortunately, Disulfiram does not reduce cravings. Consequently, research has shown that most recovering alcoholics are eventually noncompliant with taking Disulfiram, which renders the treatment ineffective. Nonetheless, Disulfiram has been shown to be effective with higher-functioning alcoholics with high motivation to quit drinking such as those facing consequences from the law. Disulfiram can also be used as a temporary treatment until other treatments and supports are put in place (Levinthal, 2016).

Acamprosate is another drug used in the post-acute phase of recovery. Acamprosate reduces some of the PAWS symptoms including insomnia, anxiety, and restlessness.

Acamprosate also helps reduce cravings and appears to be moderately effective in helping alcoholics maintain abstinence (CSAT, 2009).

Naltrexone is an opioid antagonist. It both reduces cravings for alcohol as well as alcohol’s rewarding effects. Therefore, it may serve to help maintain abstinence as well as to limit heavy drinking for someone who does chose to drink. Additionally, Naltrexone is available in as an extended-release injectable which last for one month, which can help overcome problems with noncompliance of taking a daily medication (CSAT, 2009). Naltrexone can stimulate withdrawal symptoms. So, it is also used for post-acute treatment after detoxification is nearly complete (Galbicsek, 2021).

Psychosocial Approaches to Treatment of AUD

Psychosocial approaches can also be effective in the treatment of an AUD and can be carried out in conjunction with pharmaceutical treatments. One of the first psychosocial approaches found to be effective in treating AUD was the self-help group, Alcoholics Anonymous (AA). Founded in 1935, AA is a fellowship of alcoholics who meet regularly to support each other in maintaining sobriety. Members follow the AA’s twelve step program of recovery which starts with the member acknowledging that they are “powerless over alcohol” and that their lives had become “unmanageable”. AA is spiritually focused with a strong Christian influence, though inclusivity of all faiths, even atheism, is promoted. The second step of the program involves turning one’s will and life over “to the care of God as we understand Him” (Levinthal, 2016, p. 187). Meetings primarily revolve around members sharing their own stories and giving each other mutual support along with reviewing the 12-steps of the program. New members are encouraged to find a more experienced member to be their sponsor for additional support outside the meetings. AA has grown to be a worldwide movement with over 2 million members making it the largest treatment program in existence (Levinthal, 2016).

Other self-help programs exist and are moderately effective in treating AUD as well.

These programs often differ from AA on one or more significant points. Some AA critics don’t care for the spirituality or reliance on a higher power outside of oneself. Others don’t agree with the commitment to abstinence from alcohol required by AA, but rather seek to drink alcohol in moderation. There continues to be much debate about whether programs based on abstinence are the most effective or programs based on moderation. Although, one addiction counselor has pointed out that convincing someone who wishes to drink in moderation to pursue total

abstinence is needless. This is because if the individual attempts a program to drink in moderation and fails, then they will most likely convince themselves of the need for abstinence (Levinthal, 2016).

Other psychosocial treatments involve working with a professional counselor in either individual or group therapy. Counselors have many theoretical approaches that they may draw upon. Three of the more prominent approaches used with AUD are Cognitive Behavioral Coping Skills Therapy (CBCST), Motivational Enhancement Therapy (MET), and Twelve-step Facilitation Therapy (TFT). CBCST works with the client to change their distorted thinking, build their self-esteem, and build positive coping skills. MET works on building the clients motivation for change. TFT teaches the 12-step model and encourages participation in AA as a complement to counseling. A comparative study of these three approaches showed all three to be effective treatments, though TFT showed greater long-term abstinence than the other two approaches (Levinthal, 2016).

While various approaches have been shown to be moderately effective in the treatment of AUD, it is important to consider some of the key factors in preventing relapse, four of which can be found in the AA model. First is accountability to another person, second is the substitution of a healthy activity for the alcohol, third is developing supportive relationships, and four is spirituality (Levinthal, 2016).

Significance of AUD for the Counseling Profession

Besides the obvious implication that counselors play an important role in the treatment of AUD through individual and group counseling, there are some more subtle points that counselors should be aware of. First it is important for counselor’s to be aware that AUD is highly comorbid

with substance abuse disorders as well as other psychiatric disorders such as anxiety, depression, and Borderline Personality Disorder (Howe, Fisher, Atkinson, & Finn, 2021). Therefore, it is entirely possible that a counselor may start seeing a client with AUD for another reason. The effective counselor will recognize the AUD and the role it plays with respect to the client’s treatment goals and address it accordingly.

Another subtle point a counselor should be aware of is the importance of their role in education and prevention regarding alcohol and substance use. Counselors can benefit clients who may be at risk for developing an AUD by providing them with information and resources and sometimes correcting misperceptions. For example, a counselor may want to address the common misperception that some alcoholic beverages, such as beer, are safer than others.

Another important point to address that the client may not be aware of is the possibility of death through asphyxiation and aspiration of vomit in addition to motor vehicle and other types of accidents (Capuzzi & Stauffer, 2016). Identifying at risk clients and providing them with education and resources may help them to keep from developing an AUD in the first place.

Conclusion and Future Implications

The implications of this essay for future counselors are the importance of identifying clients with an AUD as well as those at risk of developing an AUD so that appropriate resources and referrals can be provided. This is especially important for the client who decides to detox as medical supervision may be needed to do so safely. Another important implication is that there are a variety of treatment approaches which are moderately effective and none which are highly effective. A well-prepared counselor should have knowledge of a variety of resources including how to obtain inpatient treatment, outpatient treatment, and support groups that are available.

Finding the treatment approach that best matches the needs of the client is more likely to lead to a successful recovery as is combing multiple approaches such as pharmaceutical treatment along with counseling along with support groups. Finally, regardless of the approach used, the counselor should be aware of the keys of successful treatment including accountability to another person, substitution of a healthy activity for the alcohol, developing supportive relationships, and spirituality. The effective counselor needs to find ways to incorporate these keys of success into the clients treatment.

References

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Boston, MA: Pearson ISBN-13: 9780133998641

Center for Substance Abuse Treatment. (2009) Incorporating alcohol pharmacotherapies into medical practice (Treatment Improvement Protocol (TIP) Series, No. 49).

Substance Abuse and Mental Health Services Administration. https:// www.ncbi.nlm.nih.gov/books/NBK64041/

Galbicsek, C. (2021, February 19). Alcohol detox. Alcohol Rehab Guide. https:// www.alcoholrehabguide.org/treatment/alcohol-detox/

Gateway Foundation (2020, April 27). The dangers of mixing drugs and alcohol. https:// www.gatewayfoundation.org/addiction-blog/the-dangers-of-mixing-drugs-and- alcohol/

Howe, L. K., Fisher, L. R., Atkinson, E. A., & Finn, P. R. (2021). Symptoms of anxiety, depression, and borderline personality in alcohol use disorder with and without comorbid substance use disorder. Alcohol, 90, 19–25. https://doi- org.lopes.idm.oclc.org/10.1016/j.alcohol.2020.11.002

Juergens, J. (2021, March 30). Alcohol detox. Addiction Center. https:// www.addictioncenter.com/alcohol/detox/

Levinthal, C. (2016). Drugs, behavior, and modern society (8th ed.). Upper Saddle River, NJ: Pearson Publishing ISBN-13:9780134003047

National Institute on Alcohol Abuse and Alcoholism. (2014). Harmful interactions (NIH Publication, No. 13-5329). https://www.niaaa.nih.gov/publications/brochures-and- fact-sheets/harmful-interactions-mixing-alcohol-with-medicines

National Institute on Alcohol Abuse and Alcoholism. (2021). Hangovers (Brochure). https:// www.niaaa.nih.gov/publications/brochures-and-fact-sheets/ hangovers#:~:text=A%20hangover%20refers%20to%20a,sweating%2C%20and% 20increased%20blood%20pressure.

National Institute on Alcohol Abuse and Alcoholism. (2021). Interrupted memories: Alcohol- induced blackouts (Brochure). https://www.niaaa.nih.gov/publications/brochures-and- fact-sheets/interrupted-memories-alcohol-induced-blackouts